Antenatal care Flashcards
Important antenatal discussions
US Exercise, diet, smoking, alcohol Pelvic floor exercises Optimal fetal positioning Perineal massage Signs of labour When to come in Hospital access Pain management 3rd stage labour management Vitamin K and Hepatitis B Length of stay EMS Breastfeeding
Investigations required antenatal
Booking
24-28 weeks
34-36 weeks
40 weeks
Investigations at booking visit
Blood group pap smear Hb Antibodies RPR Hep B.Hep C Rubella HIV Syphillis MSU, GBS Gonorrhea, chlamydia Iron
Investigations at 24-28 weeks
Hb
Antibodies
OGTT
Urine
Investigations at 34-36 weeks
Hb
Antibodies
RPR
Investigations at 40 weeks
Hb
Antibodies
Examination requirements at each antenatal visit
BP Edema, reflexes, clonus Abdominal->gestation calculation and size Presentation 1/5 palpable Liquor FHS Fetal movement
Antenatal visit schedule
4/52 to 28
2/52 to 36
1/52 to delivery
Common complaints in pregnancy, cause and treatment
Morning sickness Carpal tunnel syndrome Vaginal discharge Pelvic pain Heartburn Varicose veins Hemorrhoids
History for each subsequent visit
General health Fetal well being Leakage of fluid Vaginal bleeding Contractions/abdominal pain Preeclampsia-->headache, visual disturbance, RUQ pain
What is biophysical profile
Combination of non-stress test and US
Components of BPP
- NST–>variation of fetal heart
- Breathing: >1 episode of rhythmic breathing movement of 30sec or more in 30 min
- Movement >3 discrete body/limb within 30 minutes
- Muscle tone: >1 episode of extension with return to flexion or opening/closing of hand
- Determination of amniotic fluid index
Normal amniotic fluid volume
800-1000ml at 36-37 weeks
In T2 what does the AFI represent
Fetal urine output
If AFI low in T2 what does it indicate
Uteroplacental dysfunction-> -ve oxygenation, fetus preferentially shunts blood to brain and heart->kidney underperfused= -ve urine output= -ve amniotic fluid
What value of AFI is adequate, oliohydramnios and polyhydramnios
Adequate= 5cm Oliohydramnios= 25 cm
Most common cause of oligohydramnios
Ruptured membranes
IUGR in 60%
Causes of polyhydramnios
Fetal malformation (anencephaly, esophageal atresia), genetic Maternal diabetes Multiple gestation Fetal anemia Viruses
What are complications of polyhydramnios
Uterine overdistension->preterm, PROM, fetal malposition, uterine atony
Caffeine
In coffee, tea, chocolate, soft drink
>300mg may +risk of abortion
Insomnia, regurgitation, reflux, urine frequence
Exercise and CI
No evidence to decrease activity
If regular before should continue
Relieves stress, anxiety, +self esteem and shortens labor
If +time in supine, should avoid in T2/3
Should stop if experience oxygen deprivation–>extreme fatigue, dizzy, SOB
CI to exercise: IUGR Persistent vaginal bleeding Incompetent cervix Risks for preterm ROM HTN, pre/eclampsia
Nausea and vomiting
Common, 50% in T1
If severe- dehydration, electrolyte imbalan
Mild->avoid spicy/fatty foods. Small frequent meals. Inhale peppermint. Drink ginger teas.
Severe->IVF (with glucose, to reduce the ketosis which can exacerbate the nausea), supplements, antihistaine, metoclopramide.
Heartburn
30% Relaxation of LES Eliminate spicy/acidic Small, frequent Sit up Reduce liquid with meal Sleep with head elevated Liquid antacids, H2 inhibitors Reduce amount of food before bed
Constipation
Common
+fiber, +liquids, Metamucil
Avoid enemas, strong cathartics and laxatives.
Varicosities
Common in lower extremeties and vulva
Chronic pain, thrombophlebitis
Avoid garments that restrict in the knee/upper leg
Support stocking
+periods of rest with elevation of lower extremities
Hemorrhoids
Cool sitz baths Stool softners \+fluid and fiber Hemorrhoidal ointment Topical anaesthetic spray/steroid cream Most improve after delivery Hemorrhoidectomy can be performed safely in pregnancy if required
Leg cramps
50%
Massage and stretching
Back pain
Progressive Minimise time standing Wear support belt Paracetamol Exercises to strengthen back Supportive shoes Gentle back massage
Round ligament pain
Sharp, bilateral, unilateral groin pain
+In T2
Get on hands and knees with head on floor and buttocks in the air
Sexual intercourse and contraindications
No restrictions in a normal pregnancy
Nipple stimulation, penetration and orgasm can +oxytocin and prostaglandin= uterine contractions
CI: ruptured membrane, placenta previa, preterm labor
Employment
Should avoid activities which+ risk of falls/trauma
Travel
Best time is T2->past risk of miscarriage in T1, and not yet preterm labor of T3
Stretch out for 10 minutes every 2 hours
Bring copy of medical record
Wear seat belt in car
No additional risk with air travel
Usual travel precautions depending on destination
When should a pregnant woman contact her obstetrician
Vaginal bleeding
Leakage
Rhythmic abdominal cramping/back pain >6hr does not improve with hydration/lying supine/changing postition
Progressive and prolonged abdominal pain
Progressive vomiting, can’t hold down any food/water for 24 hours
Seizure
Progressive severe headache, visual chages, generalised edema
Pronounced decrease in frequency/intensity of fetal movements
Goals of first antenatal visit
Health of mother and fetus
Identify conditions affected by pregnancy
Identify factors that affect pregnancy
Determine the model of care
History in first antenatal visit
Past obstetric history->pregnancies, delivery, ectopics, miscarriage, SVB, C section
Gynaecological history: LMP, pap smears, contraception
Calculate EDD
FHx->medical conditions, congenital, HTN, diabetes
MHx, medications, supplements
SHx, relations
Allergies
Investigations
Psychological
Booking examination
General inspection- demeanour, tatoos, scars, rashes, pallor, jaundice Spine- scoliosis, kyphosis Vitals- BP Thyroid CVS- heart murmus Respiratory Breast examination Abdominal examination- inspect, palpate and auscultate Bimanual not usually requires Legs- varicose and edema
Where is fetal heart heard early and late in pregnancy
Early- midline of uterus
Late- position of anterior shoulder
Risk factors identifiable in pregnant woman
Age > 35 Evidence of post partum psychiatric Previous pregnancy/birthing issues Medical history->DM, HTN, renal/heart Drug use Obesity Short Parity when >3
Advice to pregnant women on onset of labour
Regular painful contractions from small of back to lower abdomen->come to hospital when contractions every 5-10 minutes
ROM + gush of fluid->come to the hospital
Bloody/mucus show may not be labour, if with contractions contact midwife, go to delivery unit.
Best to come in if think in labour
General advice for healthy pregnancy
Diet, exercise, weight gain Smoking, alcohol, drugs Iron and folate Get someone else to change cat litter tray Avoid soft cheeses, unpasteurised, pate
Up to 10, 10-14, 20 weeks gestation, how accurate is the CRL
+/- 5 days 20 weeks
Most accurate measure for gestation assessment in second trimester and third trimester
In second- BPD
In third- femur
What to arrange at first visit
Confirm pregnancy Dating USS Routine bloods Shared care arrangements- refer to hospital CFTS
When should urine be checked
When +BP
When can fetal parts be palpated
From 28 weeks
When does fetal head descent become relevant
When >36 weeks
When is Rh status rechecked
at 26-28 weeks
When is anti-D given
28 weeks and 34 weeks
When is Hb and syphillis repeated
36 weeks
When is IOL offered post dates
41-42 weeks
Woman presents pregnant, what do you tell them
Congratulate
Ask if well
Where she can book for the birth will be determined by health and progress, medical cover
History from woman presenting pregnanct
Full history->obstetric, gynae, medical/surgical, social, family
LMP, cycle, contraception
Calculate EDD: add 9 months and seven days to LMP if regular
Feelings about the pregnancy
Examination for woman presenting pregnant
General- BP CV Respiratory Thyroid Breast Abdominal Vaginal?
When to book into hospital
As soon as possible
Decision about care
Given hand held record
Over investigations, USS, first trimester screening
Arrangements following first visit
To return after investigations
Monitor general health
